Provider Demographics
NPI:1073177291
Name:MORIN, PETRA M
Entity Type:Individual
Prefix:
First Name:PETRA
Middle Name:M
Last Name:MORIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 W 53RD ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-4069
Mailing Address - Country:US
Mailing Address - Phone:786-499-7553
Mailing Address - Fax:
Practice Address - Street 1:18255 NW 68TH AVE APT 619
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-3539
Practice Address - Country:US
Practice Address - Phone:786-499-7553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-71989106S00000X
FL1-24-70856103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty